PROSPECTIVE CASH-PAY CLIENTS

Please fill out the form below to get started. We will be in contact after your form has been submitted.

After completing this form, please keep an eye on your email for follow-up information.

CLIENT INFORMATION

Client Name

First name

Last name

I am interested in:

What type of therapy are your primarily hoping for?

Telehealth

In office

No preference

Who is filling out this form?

Client Date of Birth

Month

Day

Year

Phone

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Reason for Seeking Services

Please provide general information about what you hope to address here. This will help us to match you with the right therapist to meet your needs.

Check this box to opt in to text message alerts

Yes, I agree to receive text messages regarding Champion Family Therapy communication

No, I choose to opt-out of texting at this time

Please be aware, we are unable to offer cash-pay services to any clients with OHP due to legislative limitations.